Facts and Consequences: Legality, Incidence and Safety of Abortion Worldwide

Susan A. Cohen

First published online: November 20, 2009

Around the world, according to a new Guttmacher Institute report, Abortion Worldwide: A Decade of Uneven Progress, as contraceptive use continues to increase, levels of unintended pregnancy and abortion are declining. Of the approximately 42 million abortions that do occur worldwide, almost half are performed by unskilled individuals, in environments that do not meet minimum medical standards or both. Virtually all of these unsafe abortions take place in the developing world, where the unmet need for contraception remains high and very restrictive abortion laws often are the norm.

In the developed and developing world alike, antiabortion advocates and policymakers refuse to acknowledge the facts that abortion's legal status has much less to do with how often it occurs than with whether or not it is safe, and that the surest way to actually reduce the incidence of abortion is to reduce the incidence of unintended pregnancy. While they debate, obfuscate and insist on legal prohibitions, the consequences for women, their families and society as a whole continue to be severe and undeniable.

The lack of qualified medical providers, the stigma associated with illegal abortion, poor health systems and grinding poverty all contribute to the high health risks and to the social and financial costs of unsafe abortion. The public health tragedy caused by unsafe abortion is all the more so because it is largely preventable, by improving the quality and availability of postabortion care, by making abortion legal and increasing access to safe services, and—because almost every abortion is preceded by an unintended pregnancy—by expanding access to contraceptive information and services.

Illegal Abortion Is Usually Unsafe Abortion

Throughout Europe, except for Ireland and Poland, abortion is broadly legal, widely available and safe. The United States legalized abortion nationwide in 1973, in part because of the clear evidence that restrictive laws were not ending abortion but were exacting a significant public health toll, notably on lower-income women who could not travel or pay for safe services. Almost immediately afterward, pregnancy-related deaths and hospitalizations due to complications of unsafe abortion effectively ended. The United States was not the first country and has been far from the last to recognize this relationship and move to liberalize its law.

China was the first large developing country to enact a liberal abortion law—in 1957. The Soviet Union and the central and western Asian republics enacted similar laws in the 1950s. Over the next 50 years, abortion become legal on broad grounds in a wide range of less developed countries, including Cuba (1965), Singapore (1970), India (1971), Zambia (1972), Tunisia (1973), Vietnam (1975), Turkey (1983), Taiwan (1985), Mongolia (1989), South Africa (1996) and Cambodia (1997). Indeed, the worldwide trend in abortion law has continued to be toward liberalization. And since 1997, another 21 countries or populous jurisdictions have liberalized their laws, including Colombia, Ethiopia, Iran, Mexico City, Nepal Portugal and Thailand. During this same period, only three countries—El Salvador, Nicaragua and Poland—have increased restrictions.

Today, 60% of the world's 1.55 billion women of reproductive age (15–44) live in countries where abortion is broadly legal.

The remaining 40% live where abortion is highly restricted, virtually all in the developing world. In Africa, 92% of women of reproductive age live under severely restrictive laws; in Latin America, 97% do. Ironically, the abortion laws governing most of the countries in these regions are holdovers from the colonial era, imposed by European countries that have long ago abandoned such restrictive laws for themselves.

In a country such as Uganda, about 300,000 abortions take place each year, notwithstanding the fact that abortion is legal only to save a woman's life. Unsafe abortion there is a leading cause of pregnancy-related death. Moreover, at current rates, half of all Ugandan women will require treatment for complications related to abortion at some point in their lives.

The Heavy Toll of Unsafe Abortion

The fact is that almost all unsafe abortions occur in the developing world (see chart). According to the World Health Organization, unsafe abortion is the cause of 70,000 maternal deaths each year—or one in eight pregnancy-related deaths among women. That translates to seven women per hour. Approximately eight million more women per year suffer postabortion complications that can lead to short- or long-term consequences, including anemia, prolonged weakness, chronic inflammation of the reproductive tract and secondary infertility. Of the women who experience serious complications each year, nearly three million never receive treatment.

UNSAFE ABORTIONS

Of the almost 42 million abortions that take place around the world each year, about 20 million are unsafe and virtually all of those occur in developing countries.

Source: Guttmacher Institute, 2009.

Restrictive laws have much less impact on stopping women from ending an unwanted pregnancy than on forcing those who are determined to do so to seek out clandestine means. In countries with such restrictive laws, women who can pay can sometimes find a qualified provider willing to perform an abortion; however, the vast majority of women in poor countries are too poor to avail themselves of this underground network. In Guatemala, for example, where 37% of the population lives on less than $2 a day, the estimated cost of an illegal abortion carried out by a private medical doctor or in a private medical clinic ranges between $128 and $1,026. In Uganda, where 97% live on less than $2 a day, the price of an abortion from a professional source is $6–58. And in Pakistan, 66% live on less than $2 a day, and the average fee for a doctor-assisted abortion is $50–104.

The measurable effect of these economic realities, which relate directly to the secrecy and stigma attached to abortion where the law and culture are disapproving, shows up in the high rates of death and disability that women suffer from taking the decision into their own hands. Women themselves or untrained providers use a variety of traditional and often dangerous methods to end an unwanted pregnancy, such as inserting sticks into the vagina, drinking bleach or applying extreme pressure to the abdomen, which often result in severe complications, such as hemorrhage. Fear of being discovered breaking the law or being accused of promiscuity causes many women to choose secrecy over their own safety. The shaming and blaming of women who have abortions in many of these cultures is an impediment to their seeking out the necessary postabortion medical care to save their lives.

About 40% of women who have a clandestine abortion experience complications that require treatment. Yet, even if a woman makes it to a medical facility, too many health centers in developing countries simply do not have the capacity to deliver quality care for the complications resulting from an unsafe abortion. Health systems in these countries are usually strained and inadequate to begin with. However, the weak infrastructure is often further compounded by a lack of trained personnel and supplies, as well as judgmental or punitive attitudes among staff toward women seeking postabortion treatment. Even contraceptive counseling to help women avoid a future unwanted pregnancy is often unavailable: Studies of women treated for complications of clandestine abortion in the Dominican Republic, Peru and a poor southern state in Mexico found that women often left without a contraceptive method.

The costs in women's lives and health because of unsafe abortion are a human tragedy, but there are also costs to society. To provide care for the illness and disability associated with unsafe abortion, a government spends, on average, at least $114 per case in Africa and $130 in Latin America; in these regions, the total per capita spending on health care is $48 and $329, respectively.

Each year, an estimated five million women are hospitalized for the treatment of abortion complications, at a cost of at least $460 million. However, even in countries with highly restrictive laws, these high financial burdens can be avoided or at least reduced through prevention. According to a case study in Nigeria, for example, the cost of providing contraceptive services to enable women to avoid the unintended pregnancies that end in unsafe abortion would be only one-quarter of what Nigerian health facilities spend to provide postabortion care.

Toward Legality and Safety

As more developing countries have reformed their abortion laws, new evidence is accumulating that legal abortion saves women's lives. By 2002 in South Africa, for example, six years after liberalizing its abortion law, deaths due to unsafe abortion dropped by at least 50% and the number and severity of postabortion complications fell dramatically as well. Similarly, according to Nepalese government hospitals records, soon after abortion was legalized in 2004, the number of women admitted for complications of unsafe abortion and the severity of those complications declined markedly; pregnancy-related deaths in Nepal also declined.

Changing the law is only the beginning, however, and by itself is no guarantee that unsafe abortion will cease to exist. For example, abortion has been legal in Zambia since 1994. However, safe services remain out of reach for most women there for several reasons: There is only one doctor per 8,000 individuals, a woman seeking an abortion must obtain the consent of three physicians, many doctors will not perform abortions for religious or moral reasons and, in the few hospitals where legal abortions are available, the cost is prohibitive. And in India, where abortion has been legal for more than 30 years, about three unsafe abortions take place for every two safe procedures. Most women cannot afford to pay private-sector prices, so they go to public health facilities where quality of care is poor. Physician training is often inadequate, sanitary medical conditions are lacking, and privacy and confidentiality are often compromised. Moreover, authorized abortion facilities in India routinely turn a woman away if she arrives alone, is unmarried or is married but childless.

Therefore, even after legalization, more hurdles remain. Providers must be willing to step up and receive training. Safe services in hygienic conditions must be made widely available and affordable. And then, the even longer process of changing cultural attitudes can begin, so that the stigma associated with providing and obtaining abortions can lessen and safe services can become normal and accepted.

Making Abortion Less Likely

Between 1995 and 2003, the global abortion rate dropped by 17%. Africa and Asia saw a 12% decline during the same period, and Latin America and the Caribbean experienced a drop of 16%. In Eastern Europe, though, the abortion rate plummeted by 51%. Notably, the largest decline occurred in the former Soviet bloc countries, where abortion has been legal the longest and is widely available.

Clearly, it is not the changes in abortion's legal status that can explain the decreased abortion rate worldwide, since many more countries liberalized access to abortion than restricted it. Significantly, though, during this same period, contraceptive use worldwide increased and unintended pregnancy rates fell. Where contraceptive use increased the most, abortion rates dropped the most. Contraceptive use has increased globally and in every region of the world, but it remains extremely low in Africa (see chart). Not surprisingly, therefore, the world's highest levels of unintended pregnancy can be found in Africa—86 per 1,000 women aged 15–44, almost three times the rate in western Europe. Indeed, the 26% of women in developing countries who are at risk of unintended pregnancy but do not practice contraception or use only traditional methods account for 82% of the 75 million unintended pregnancies that occur each year.

CONTRACEPTIVE USE

In all regions of the world, contraceptive use is on the rise, but it still remains extremely low in Africa.

Source: Guttmacher Institute, 2009.

Where contraceptive use is high, abortion can be legal and widely available, and still relatively rare. The lowest abortion rates in the world can be found in western and northern Europe, where abortion has been legal for decades but access to contraception is widespread. In the United States, the story is similar. In 1973, right after abortion was legalized nationwide, the U.S. abortion rate increased somewhat as safe legal abortions replaced unsafe illegal ones. The rate peaked in 1981 and has been on a steady decline since then to 19 per 1,000 women aged 15–44 today, its lowest level since 1974.

Promises to Keep

All governments—donor and recipient countries alike—can do much more to save women's lives, and to protect and promote their health. Indeed, virtually every government promised to do so at the 1994 International Conference on Population and Development (ICPD) in Cairo and at the 1995 Fourth World Conference on Women in Beijing. Almost all the world's governments are committed to achieving the Millennium Development Goals by 2015, which also include a call for universal access to reproductive health services.

The United States has been and remains the single largest donor to family planning and reproductive health programs overseas, but according to its commitments at the ICPD and the large unmet need for services, the United States should be providing at least $1 billion annually in aid—about twice the level it is allocating now. Increasing access to contraceptive services is at the core of the U.S. program. As such, the United States is making a significant contribution toward reducing the need for abortion altogether and the likelihood of unsafe abortion by bringing down the rates of unintended pregnancy.

The United States is also helping to reduce complications of unsafe abortion through its support for programs to increase access to and improve postabortion care. This includes not only treatment for septic or incomplete abortion, but also essential postabortion family planning counseling and services to lessen the chances of another unintended pregnancy. The U.S. Agency for International Development itself recently affirmed its commitment to these life-saving interventions (see box, page 6).

No U.S. funds may be used to pay for the provision of abortion services, however, because of the 1973 law known as the Helms amendment. This puts the United States at odds with most other donor governments, which do fund the full range of sexual and reproductive health care, including safe abortion services. In fact, in October, the United Kingdom's Department for International Development (DFID) updated its policy on abortion. "DFID supports safe abortion on two grounds," according to the new policy. "First, it is a right. Women have the right to reproductive health choices. Second, it is necessary." This is the case because one-fifth of all pregnancies worldwide end in abortion and without access to safe abortion services, women will continue to resort to unsafe procedures.

Britain's International Development Minister, Mike Foster, emphasized in a statement that "better access to family planning information and contraception is of vital importance," but it is not enough. To that end, DFID will give even greater support to such activities as training in safe abortion techniques, including the provision of medical abortion services; improving the conditions under which abortions are provided and the quality of services; increasing the information and education provided to health personnel and to women; and enhancing life-saving postabortion care. In addition, where abortion is illegal and maternal mortality is high, "DFID will make the consequences of unsafe abortion more widely understood, and will consider supporting processes of legal and policy reform."

As for the U.S. responsibility, because of its historic leadership role in this field globally—and now unencumbered by counterproductive policies such as the Mexico City policy (also known as the global gag rule)—the United States needs to ramp up further its financial commitment to help women in the developing world prevent unintended pregnancy. It can do more to help mitigate the consequences of unsafe abortion, including the likelihood of repeat unsafe abortion. And even within the confines of the Helms amendment, the United States can and should support abortion in cases necessary to save a woman's life and in instances of rape or incest. Until the Helms amendment is repealed altogether, the fact remains ever clearer that it only consigns more women to needless death and disability, and has no impact on making abortion less likely.

Postabortion Care Must Include Family Planning

Leading up to this year's triennial world congress of the International Federation of Gynecology and Obstetrics (FIGO) in Capetown, South Africa, FIGO along with the International Confederation of Midwives (ICM), the International Council of Nurses (ICN) and the U.S. Agency for International Development produced a joint statement on September 25 calling attention to the critical importance of postabortion family planning information and services.

The rationale for the statement is summarized in a quote from a meeting on postabortion care that took place during the 1994 ICPD in Cairo: "If the woman we treat for post abortion complications is there because she could not get contraception, we have failed her. If she leaves without family planning, we have failed her twice." The consensus statement calls for several key interventions to improve postabortion care. They include:

• providing a wide range of contraceptive methods, accompanied by simple written information;

• ensuring that postabortion family planning is the standard of care for doctors, nurses and midwives; and

• encouraging health professionals, especially members of FIGO, ICM and ICN, to assume an advocacy role to improve health outcomes for women by providing quality postabortion family planning services.

The statement notes the large proportion of pregnancies worldwide that end in abortion—spontaneous or induced—and that some women who have just had an abortion are at risk of a repeat unintended pregnancy as early as 2–3 weeks later. Accordingly, access to high-quality family planning information and services can make a significant difference in reducing the likelihood of another unintended pregnancy and abortion, safe or unsafe.

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